Review Br. J. Surg. 1992, Vol. 79, September, 877-881
B. Duarte, K. K. Nagy and J. Cintron Department of Surgery, University of Illinois Hospital, 840 S. Wood Street, Chicago, Illinois 606 12, USA Correspondence to : Dr B. Duarte
Perforated duodenal diverticulum Duodenal diverticula are present in up to 20 per cent of the population but f e w patients require surgery ,for acute complications. Perforation is the rarest of these complications; only I01 afected patients have hetw reported in the world literature. These reports of perforated duodenal diverticulum are reviewed and strategies f o r the diagnosis and management of this unusual condition are discussed.
Since the incidence of duodenal diverticulum is second only to that of diverticulum of the colon, it is surprising that this lesion does not become symptomatic more often. The clinical presentation is non-specific and the diagnosis one of exclusion. Spontaneous perforation of a duodenal diverticulum is extremely rare: just over 100 cases have been reported in the world literature. Of these, only 13 were proven before operation by radiographic studies. Almost all of the reported cases required surgical treatment.
History and pathophysiology The first description of a duodenal diverticulum found at autopsy was made by Chomel in 1 7 1 0 ' ~ ~ More . than 200 years later, in 1916, Case demonstrated the condition on a radiograph3. In 1915, Forsell and Key diagnosed a diverticulum on an upper gastrointestinal radiograph using contrast agent and performed the first successful duodenal diverticulectomy I . As these radiographic studies became more frequently used, the reported incidence of duodenal diverticulum increased: it has varied from 1 to 5 per cent in upper gastrointestinal radiographic s t ~ d i e s ~ and - ~post-mortem analyses have shown incidences of up to 22 per cent6p8. The aetiology of the duodenal diverticulum remains unknown. The most widely accepted theory, however, implicates a weakness of the intestinal all',^.^. Diverticula are usually classified into three types. A true congenital diverticulum includes all the layers of the intestinal wall. This is the rarest type and is thought to result from an abortive attempt to form a supernumerary pancreas'. Only two perforations of a true congenital diverticulum have been reportedg. Primary acquired pulsion diverticulum, or pseudodiverticulum, is the commonest type. Possibly, these diverticula protrude through the weak areas of intestinal wall where blood vessels penetrate and contain only mucosal and serosal layer^',^,^. An alternative theory is that increased intraluminal duodenal pressure occurs secondary to a chronic duodenal obstruction caused by the superior mesenteric vessels crossing over the bowel". Secondary acquired diverticulum is the second commonest type and is believed to be caused by traction on a particular area of the duodenum by scarring or adhesions from a previous local inflammatory reaction (cholecystitis, lymphadenitis or duodenal ulcer). This type contains all the layers of the intestinal wall and is not a true diverticulum, simply an outpouching of the intestinal lumen. Secondary diverticula are found most frequently in the first part of the duodenum',2~'1. Most duodenal diverticula (88 per cent) are located along the pancreatic or mesenteric border, supporting the theory that they are caused by a weakness in the intestinal wall2. Approximately two-thirds are located in the second part of the duodenum and many are imbedded in the pancreas214. Most are within 2.5 cm of the ampulla of Vater and are therefore known as perivaterian; 16 per cent are multiple4.
0007-1323/9?/090877-05
1992 Butterworth-Heinernann Ltd
Clinical presentation The clinical diagnosis of diverticulum of the duodenum is difficult because there is no characteristic presentation. Symptoms are vague and non-specific, and lead the surgeon to consider other more common diseases such as cholecystitis, cholelithiasis, duodenal ulcer, gastritis and pancreatitis. The diagnosis is thus one of exclusion. Duodenal diverticula are commonly associated with other lesions of the gastrointestinal tract, such as diverticula elsewhere in the bowel, biliary tract disease, peptic ulcer and hiatus hernia'. The high incidence of other gastrointestinal diseases is probably related to the age of affected patients. Most are at least 50 years old, although perforation has been reported in a child and in a Not all diverticula are symptomatic, indeed most run a benign course, only 10 per cent having clinical relevance4. One isolated study has reported that 74 per cent of duodenal diverticula cause serious symptom^'^. The possible complications of duodenal diverticula are: common bile duct obstruction with cholangitis or jaundice; acute and chronic recurrent pancreatitis; partial duodenal obstruction; diverticulitis or peridiverticulitis; ulceration with or without haemorrhage; fistula to adjacent organs including the gallbladder, common bile duct, colon and aorta; enterolith formation with distal small intestinal obstruction or penetration into adjacent organs; malignant degeneration; torsion of the diverticulum; diarrhoea secondary to a blind loop syndrome; and perforation",' l.I5-l7.
Perforation Perforation is considered to be the most serious complication but fortunately it is also the rarest; only 101 patients so affected have been reported in the world literature. Juler et al." in 1969 published a collection of 56 cases and an additional 45 from the world literature are reported here (Table 1). All of the following data are from the total of 101 patients, except.where otherwise stated. In most patients (57 per cent) diverticulitis precedes and causes the perforation. This diverticulitis follows stasis and peptic digestion' I . The smaller the stoma into the diverticulum, the more likely it is that stasis will occur49. Other causes of perforation (Table 2 ) include enterolithiasis, ulceration, increased intraluminal pressure, presence of a foreign body, blunt abdominal trauma and the presence of a gallstone. Perforation of a duodenal diverticulum has no pathognomonic signs or symptoms. In most patients (78 per cent) the onset is acute with pain localized to the right upper abdomen or epigastrium, and associated nausea and vomiting. Some patients present with chronic abdominal pain, anorexia and malaise, which may have lasted as long as 1 month. Three patients in the literature reports presented with a history of months of steatorrhoea secondary to duodenocolic fistulae' 9-29334. The sequelae of perforation include retroperitoneal abscess,
877
F F
M
70 59
44
51
78
69
61
77
33
5
1970 1970
1970
1970
1970
1972
1972
1973
1973
1973
1974
Reilly and Kune2’
Reilly and Kune”
Cavanagh”
Miller et al.23
Wolfe and
Blomstedt and Holmz5
Peutz et a1.12
Peutz et a1.I2
Peutz et a/.”
Scarpa et
Dippon”
F
F
M
79
86
80
57
70
37
54
38
7s 49
1974
1974
1974
1975
1975
1976
1977
1971
1977 I978
Sicard et a1.”
Sicard et a/.28
de Medeiros et
de Medeiros et aL9
Kellum et al.29
Ettman and Kongtawng3’
Widder~hoven~’
Hansen and Taudorfis Glasser et
F F F
M
M
F
F
F
Acute Chronic
Acute
Acute
Chronic
Chronic
Acute
Acute
Acute
Acute
Acute
Chronic
M
73
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute Acute
Chronic
Acute
Symptom onset
F
M
F
F
F
F
M
Graudins”
55
1970
Dey and Latchmorel9
F
27
1969
Turner”
Sex
Year
Age (years)
Perforated duodenal diverticulum
n.a. Acute cholecystitis
Upper gastrointestinal bleeding/pancreatitis
Duodenocolic fistula
Perforated viscus
n.a
Colonic cancer, cholecystitis, appendicitis Appendicitis, cholecystitis
Mesenteric ischaemia
Perforated viscus
Tumour
Acute cholecystitis
Perforated ulcei
n.a
Perforated viscus
Acute cholecystitis
Perforated viscus
n.a.
n.a.
Perforated viscus
Duodenocolic fistula
Acute cholecystitis
Preoperative diagnosis
Reported cases of perforated duodenal diverticulum, 1969-1990
Reference
Table I
3rd 2nd
2nd
2nd
3rd
2nd
2nd
2nd
2nd
2nd
2nd
2nd
2nd
ma.
2nd
2nd
ma.
2nd
2nd
2nd
2nd
3rd
2nd
Part of duodenum
Anterior
Whipple procedure
Diverticulectomy/ serosal patch
Diverticulectorny/ droinoge/BII
Diverticulorrhaphy/ drainage Diverticulectomy/ drainage
Diverticnlectomy
Diverticulectomy
Diverticulectomy/ omental patch/ drainage
Diverticulectomy/ drainage Diverticulectomy/ drainage
Diverticulectomy/ drainage/BlI Diverticulectom y/ drainage Diverticulectomy/ drainage
Tube duodenostomy/ drainage No surgery
Diverticulectomy
Diverticulectomy Diverticulectomy
Diverticulectomy
Diverticulectomy
Treatment
Diverticulitis/enterolith Diverticulectomy Diverticulitis n.a. Diverticulectomy Diverticulitis
Diverticulitis
Pancreas Retroperitoneum Retroperitoneum
Diverticulitis
n.a.
n.a
n.a
Diverticulitis
n.a.
Diverticulitis
Diverticulitis
Enteroliths
Diverticulitis/foreign body Diverticulitis
Diverticulitis/gangrene
ma.
Enterolith
Increased intraluminal pressure Increased intraluminal pressure
Trauma (enterolith)
Ectopic gastric mucosa
Enterolith
Cause of perforation
Transverse colon
Retroperitoneum
Anterior
Anterior
Retroperitoneum
Retroperitoneum
Retroperitoneurn
Pancreas
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Pancreas
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Ascending colon
Retroperitoneum
Area of perforation
n.a. n.a. Normal Normal Ileus, RUQ calcification Air in paraduodenal area Retroperitoneal air UGI: normal
Death Survival Survival Survival Death
Shock
None None
Chest radiograph: normal n.a. RUQ calcification
Retroperitoneal aii (retrospective) Normal n.a Normal Free air UGI: diverticuluiu UGI/LGI: fistula, diverticulum UGI: fistula, free air, diverticulum n.a. Retroperitoneal air Paraduodenal air UGI: diverticulum
Survival Survival Survival
Survival Death Survival Death Survival Survival Death Survival ma. Survival
None
Pancreatic and small bowel fistulae None n.a. None
Pneumonia, duodcnal fistula None
Respiratory failure
Enterocutaneous fistula None
None
None
None
Normal
Survival
Survival None
Retroperitoneal fistula
n.a
Sepsis
None
ma.
UGIILGI: fistula Survival
Intra-abdominal abscess None
Radiographic findings* Enterolith (retrospective)
Result Survival
Complications
2‘
E
s
(D
? 4
s
0
3 m
C
c-
n
5.
P
E
3
(D
P
n
E v
0 P
W
4
0)
I-
?
m
68
32
n.a.
n.a.
85 87
61
89
64
1979
1980
1980
1981
1981
1982 1982
1983
1984
1984
1985
1985
1985
1988
1988
1989 1989
1989
1989
Yasui et a / . 3 4
Vorster and Tatdru-”
Manny et a/.14
Manny et 0 1 . ’ ~
Scudamore et a/.-’? Scudamore et d3’
Wells38
Zamir et a / . 3 9
Haugh and McBee4’
Stebbings and Thomson4’ Stebbings and Thomson4’ Beech et a/.42
Tissot et a/.4’
El Khatib44
Vanek et a/.45 Perrott“
Van Beers et d4’
Goodman et a/.48
,
Acute
Acute Acute
Acute
Acute
F F M
F
Acute
M
M
Acute
Acute
Acute
Acute
Acute
Chronic
Acute Acute
n.a.
Perforated duodenal diverticulum Perforated duodenal diverticulum
Perforated ulcer Acute cholecystitis
Perforated ulcer
Perforated duodenal diverticulum
Perforated duodenal diverticulum
Unknown
Small bowel obstruction
Acute cholecystitis
Acute cholecystitis
n.a.
Perforated viscus Perforated viscus
n.a.
ma.
n.a. Acute cholecystitis
Duodenocolic fistula
Duodenocolic fistula
ma.
Perforated ulcer
4th
4th
2nd 2nd
2nd
2nd
2nd
n.a.
n.a.
2nd
2nd
2nd
n.a. n.a. 2nd
ma.
2nd 2nd
2nd
2nd
2nd
2nd
Retroperitoneum
Retroperitoneum
Retroperitoneum Retroperitoneum
Retroperitoneum
Lesser sac
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Anterior
n.a. n.a. n.a.
Retroperitoneum Retroperitoneum,’ pancreas ma.
Hepatic flexure
Ascending colon
Retroperitoneum
Retroperitoneum
Diverticulitis
n.a.
Enterolith ma.
Diverticulitis
n.a.
Diverticulitis
n.a.
ma.
n.a.
Increased intraluminal pressure Diverticulitis
ma.
Diverticulitis Diverticulitis Gallstones
Diverticulitis Diverticulitis
n.a.
ma.
ma.
ma.
Diverticulectomy
No surgery
Diverticulectomy Drainage
Diverticulectomy/ drainage
Diverticulectomy,’ drainage
Diverticulectomyitube duodenostomyi drainage Diverticulectomy/ drainage Diverticulectomy/ drainage Diverticulectomy/ drainage Tube duodenostomyi drainage; 6 weeks later, diverticulectomy
Diverticulectomy Diverticulectomy Tube duodenostomyi omental patch/ drainage Drainage
Diverticulectomy
Diverticulectomy Diverticulectomy
n.a.
Diverticulectomy/ vagotomyiBI1 n.a.
Diverticulectomyi drainage
None
None
Wound infection Sepsis
None
None
Metabolic alkalosis
None
Intra-abdominal abscess Duodenal fistula
None
None
Duodenal fistula
Pancreatitis
Duodenal fistula Duodenal fistula
None Duodenal fistula
None
None
None
Duodenal fistula
Survival
Survival
Survival Death
Survival
Survival
Survival
Survival
Survival
Survival
Survival
Survival
Survival Survival
Survival Survival
Survival
Survival
Survival
Survival
Survival
Survival
UGI/CT: perforated diverticulum CT: perforated diverticulum
Normal UGI: diverticulum
Normal
Retroperitoneal air UGI: diverticulum with extravasation and paraduodenal mass UGI: diverticulum with extravasation CT: abscess
Normal
Ileus
Normal
n.a.
US: pancreatic mass
UGI: diverticula
Normal
Paraduodenal air
Normal UGI: normal n.a. ma.
n.a.
UGI/LGI: fistula, diverticulum
UGI: fistula, diverticulum
UGI: diverticula
Normal
*Radiography was plain abdominal unless specified. ma., Not addressed in reference paper. BII, Billroth I1 gastrojejunostomy: UGI. upper gastrointestinal contrast radiography; LGI, lower gastrointestinal contrast radiography; RUQ, right upper quadrant of abdomen; US, ultrasonography of abdomen; CT, computed tomography
52
77
69
10
70
71
F
F
M
M
F
72
61
M
M F
n.a.
ma.
Acute
n.a.
Acute
F
Chronic
Chronic
Acute
Acute
F
M
F
F
M
55
73
50
1979
Yasui et a/.’4
70
56
1979
1979
Donald-’-’
Donald-’-’
D
L
2
(D
5
F
?
3
C
r,
3. c)
(D
2’
p
=L
(D
0.
0
C
P P
% (D
0,
-h
%
Perforated duodenal diverticulum:
B. Duarte et al.
Table 2 Causes o f duodenal diverticular perforation in I 0 1 patients
Cause of perforation Diverticulitis Enterolithiasis Ulceration Increased intraluminal pressure Foreign body
Trauma Gallstone Unknown/not specified
No. in series of Juler et al."
present series
Total*
40 6 9 0 1 0 0 0
19 6 0 3 1 1 1 16
59 (57) 12 (12) 9 (9) 3 (3) 2 (2) 1(1) 1(1) 16 (16)
Table 4 Area ofperforation of duodenal diverticula No. in
Location of perforation
No. in series of Juler et al."
Retroperitoneum Pancreas Colon Anterior Gallbladder Aorta Lesser sac Unknown/not specified
43 4 3 2 3 2 0 0
29 4 4 4 0 0 1 4
No. in
present series
Total*
Values in parentheses are percentages. *Two patients had more than one cause specified, giving a total of 103
Values in parentheses are percentages. *Two patients had more than one location specified, giving a total of 103
Table 3 Preoperative diagnoses considered in patients with perforated duodenal diverticula
improved preoperative and intraoperative diagnosis of this condition, there is still a mortality rate of 13 per cent in the series from 1969 to the present. This high rate may be caused in part by the advanced age of the patients and associated underlying diseases. Most perforations occur retroperitoneally, but the diverticulum may also perforate anteriorly, or into the pancreas, colon, gallbladder or aorta (Table 4 ) .
Preoperative diagnosis
No. in series of Juler et a/."
Cholecystitis 15 Perforated ulcer 12 Perforated duodenal diverticulum 3 7 Appendicitis Perforated viscus 0 0 Duodenocolic fistula Bowel obstruction 2 Upper gastrointestinal bleed 2 Colonic cancer/tumour 0 Mesenteric ischaemia 0 Pancreatitis 0 Unknown/not specified 5
No. in
present series
Total
10 4 5 2 7 4 1 1
2 1 1 11
Values in parentheses are percentages sepsis, mediastinitis27, duodenocolic fistula with steator,.hoeaI 9.29.34, and gastrointestinal tract bleeding secondary to perforation into the aorta". In most instances the preoperative diagnosis is incorrect. The most common erroneous diagnoses considered are cholecystitis, perforated viscus and appendicitis (Table 3). A correct preoperative radiographic diagnosis was made in 13 of the 101 patients. Plain abdominal radiographs may show periduodenal or retroperitoneal air, or they may be entirely normal. If the diverticulum perforates anteriorly, the radiograph may demonstrate a pneumoperitoneum. Fifty per cent of the plain radiographs obtained in this series were normal; only 27 per cent demonstrated retroperitoneal or paraduodenal air. Upper gastrointestinal radiographic studies may show a diverticulum with extravasation of contrast medium. Eighty per cent of such studies obtained in this series showed a diverticulum, but only seven of these demonstrated a fistula or extravasation of contrast medium. In three cases the diagnosis was confirmed by the use of abdominal computed t ~ m o g r a p h y ~ ~ , ~ 'and . ~ ' , endoscopic retrograde cholangiopancreatography confirmed the diagnosis in The duodenocolic fistulae were demonstrated by upper and lower gastrointestinal radiographic contrast studies. Juler et al." found that eight of 56 perforated duodenal diverticula were missed during operation up to 1969. The present series of 45 patients included only a single missed perforation, perhaps because surgeons today are more aware of perforated duodenal diverticuluin as a pathological entity. Juler et al. also reported an additional eight perforated diverticula diagnosed at autopsy without previous surgical intervention. Two cases of perforation diagnosed only at a ~ t o p s y ' ~are . ~reported ~ here. According to Juler et al. the mortality rate associated with perforated duodenal diverticulum from 1907 to 1969 was 34 per cent. Even in recent times, with increased awareness and
880
Management Surgical treatment is required for only 1-2 per cent of duodenal d i v e r t i ~ u l a ' * ~, diverticulectomy .~,~~ with two-layer closure of the duodenum is the treatment of choice4. Special care should be taken to avoid injury to the distal common bile duct and ampulla of Vater because most diverticula arise in this area. If perforation has occurred, the retroperitoneum should be drained. Complications of operations to repair the 46 perforated duodenal diverticula occurred in 41 per cent of the 45 patients in the present series. The most common complication was duodenal fistula (20 per cent). Two patients ( 4 per cent) had an intra-abdominal abscess, and five (11 per cent) had continued sepsis or sepsis-related complications. Pancreatitis developed after operation in one patient ( 2 per cent), and one sustained a wound infection. Reports have been made on two patients who were successfully treated with conservative therapy a l ~ n e ~ ' , ~Juler '. et al." previously described two cases managed nono p e r a t i ~ e l y;~however, ~ ~ ~ ' after reviewing the original reports it is clear that the patient described by Fischer" in 1958 actually had a cholecystoduodenal fistula that initially mimicked a perforated duodenal diverticulum on radiography. The patient reported by Shackletonso in 1963 had a perforated duodenal diverticulum demonstrated by upper gastrointestinal radiography. The perforated duodenal diverticulum reported by Van Beers et a / . in 1989 was documented by computed tomography4'. Both patients improved initially with intravenous fluids and parenteral antibiotics. Because of their improvement with conservative therapy, their advanced ages and underlying medical problems, non-operative therapy was continued. Both patients recovered.
References 1.
Odgers PNB. Duodenal diverticulosis. Br J Surg 1930: 17:
2.
Jones TW, Merendino KA. The perplexing duodenal diverticulum. Surgery 1960; 48: 1068-84. Case JT. Roentgen observations on the duodenum. A J R A m J
592-618. 3.
Roentgen01 1916; 3: 314-26.
4. 5.
Cattell RB, Mudge TJ. The surgical significance of duodenal diverticula. N Engl J Med 1952; 246: 317-24. Whitcomb JG. Duodenal diverticulum. Arch Surg 1964; 88: 275-8.
6.
Thompson NW. Invited commentary on transduodenal diverticulectomy for periampullar diverticula. World J Surg 1979; 3: 135-6.
Br. J . Surg., Vol. 79, No. 9, September 1992
Perforated duodenal diverticulum: B. Duarte et al. 7. 8.
9. 10. 11.
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
Baldwin WM. Duodenal diverticula in man. Anai Rec 1911; 5: 121-40. Ackermann W. Diverticula and variations of the duodenum. Ann Surg 1943; 117: 403-13. de Medeiros RP, Leonard LS, Mantovani M et al. Diverticulo duodenal verdadeiro perfurado. Rev Assoc Med Brasit 1975; 21: 367-8. Smith SRG, Goode AW. Nocturnal diarrhoea: a feature of giant duodenal diverticulum. Br J Surg 1984; 71: 647. Juler GL, List JW, Stemmer EA, Connolly JE. Perforating duodenal diverticulitis. Arch Surg 1969; 99: 572-8, Peutz WH, Sannen LJMJ, Sing LH. The perforated diverticulum of the duodenum. Arch Chir Neerlandicum 1973; 25: 313-18. Hahn 0. The surgery of duodenal diverticula. Beitrag zur Klinische Chirurg 1929; 148: 255-9. Manny J, Muga M, Eyal Z. The continuing clinical enigma of duodenal diverticulum. Am J Surg 1981; 142: 596-600. Hansen TT, Taudorf E. Diverticulum duodeni perforatum med retroperitonealt emfysem. Ugeskr Laeger 1977; 139: 653-4. Beachley MC, Lankau CA. Inflamed duodenal diverticulum: preoperative radiographicdiagnosis. Dig Dis 1977;22: 149-54. Brian JE, Stair JM. Noncolonic diverticular disease. Surg Gynecol Obstet 1985; 161: 189-95. Turner RJ. Acute duodenal diverticulitis. Tex Med 1969; 6 5 : 91-5. Dey KR, Latchmore AJC. Steatorrhoea due to duodeno-colic fistulae from perforation of a duodenal diverticulum with ectopic gastric epithelium. 5 r J Clin Pract 1970; 24: 444-5. Graudins J. Stflmpfes Bauchtrauma mit Perforation eines Duodenaldivertikels. Zentralbl Chir 1970; 4 : 129-31. Reilly PL, Kune GA. Perforation of duodenal diverticula: a new hypothesis. Aust N Z J Surg 1970; 40: 40-2. Cavanagh JE. Enteroliths and perforation of duodenal diverticula. Arch Surg 1970; 100: 614-18. Miller RE, McCabe RE, Salomon PF, Knox WG. Surgical complications of small bowel diverticula exclusive of Meckel's. Ann Surg 1970; 171: 202-10. Wolfe RD, Pearl MJ. Acute perforation of duodenal diverticulum with roentgenographic demonstration of localized retroperitoneal emphysema. Radiology 1972; 104: 301-2. Blomstedt B, Holm I. Treatment of perforated duodenal diverticu1a:report ofacase. ActaChirScand1972; 138:211-14. Scarpa FJ, Sherard S, Scott HW. Surgical management of perforated duodenal diverticula. Am J Surg 1974; 128: 105-7. Dippon R. Perforation eines Duodenaldivertikels. Helu Chir Acta 1974; 41: 121-2. Sicard JL, Prandi D, Hay JM, Maillard JN. Les complications des diverticules duodenaux; a propos de quatre observations. Ann Chir 1974; 28: 537-43. Kellum JM, Boucher JK, Ballinger WF. Serosal patch repair for benign duodenocolic fistula secondary to duodenal diverticulum. Am J Surg 1976; 131: 607-10. Ettman IK, Kongtawng T. Massive gastrointestinal bleeding and perforation of a duodenal diverticulum with coexisting pancreatitis. South Med J 1977; 70: 761-3.
Br. J. Surg., Vo1.'79, No. 9, September 1992
Widdershoven GMJ. Perforated perivaterian duodenal diverticulitis. Arch Chir Neerlandicum 1977; 29: 153-7. 32. Glasser CM, Goldman SM, Roda CLP, Bronstein HD. Preoperative diagnosis of a perforated duodenal diverticulum. AJR Am J Roentgenol 1978; 130: 563-4. 33. Donald JW. Major complications of small bowel diverticula. Ann Surg 1979; 190: 183-8. 34. Yasui K, Tsukaguchi I, Ohara S ei a/. Benign duodenocolic fistula due to duodenal diverticulum: report of two cases. Radiology 1979; 130: 67-70. 35. Vorster CF, Tataru V. Das gedeckt perforierte und massiv blutende Duodenaldivertikel.Munch Med Wochenschr 1980; 122: 715-16. 36. Cox CL. Perforated duodenal diverticulitis. South Med J 1980; 73: 830. 37. Scudamore CH, Harrison RC, White TT. Management of duodenal diverticula. Can J Surg 1982; 25: 311-14. 38. Wells F. Pancreatic abscess complicating a perforated duodenal diverticulum. Br J Surg 1983; 70: 292. 39. Zamir 0, Lernau OZ, Nissen S. Tube duodenostomy - a safe method for managing perforated duodenal diverticulum. Can J Surg 1984; 27: 421. 40. Haugh DC, McBee MH. Perforation of duodenal diverticula. Contemp Surg 1984; 25: 12-5. 41. Stebbings WSL, Thomson JPS. Perforated duodenal diverticu1um:areport oftwocases. PosfgradMedJ1985;61:839-40. 42. Beech RR, Friesen DL, Shield CF. Perforated duodenal diverticulum: treatment by tube duodenostomy. Curr Surg 1985; Nov-Dec: 462-5. 43. Tissot E, Ayoun CL, Maisonnier M. Diagnostic preopiratoire d'une perforation subaigue d'un diverticule duodenal. J Chir (Paris) 1988; 125: 346-9. 44. El Khatib C . Perforated duodenal diverticulitis. W V Med J 1988; 84: 663-4. 45. Vanek VW, McNamara K, Lyras LS. Perforated duodenal diverticulum: case report and literature review. Contemp Surg 1989; 34: 36-47. 46. Perrott CAV. Perforated duodenal diverticulum - an oftenmissed diagnosis: a case report. S Afr J Surg 1989; 27: 24-5. 47. Van Beers B, Trigaux JP, De Ronde T, Melange M. Case report: CT findings of perforated duodenal diverticulitis. J Comput Assist Tomogr 1989; 13: 528-30. 48. Goodman P, Raval B, Zimmerman G. CT diagnosis of perforated duodenal diverticulum. Clin Imaging 1989; 13: 321 -2. 49. Neil1 SA, Thompson NW. The complications of duodenal diverticula and their management. Surg Gynecol Obstet 1965; 120: 1251-8. 50. Shackleton ME. Perforation of a duodenal diverticulum with massive retroperitoneal emphysema. N Z Med J 1963;62:93-4. 51. Fischer F. Gleichzeitiges Vorkommen einer durch Steinperforation entstandenen inneren Gallenfistel mit einem Duodenaldivertikel, zugleich ein Beitrag zur Differentialdiagnose des Bulbusdivertikels. Radio1 Clin 1958; 27: 35-9. 31.
Paper accepted 27 February 1992
881
B. Duarte, K. K. Nagy and J. Cintron Department of Surgery, University of Illinois Hospital, 840 S. Wood Street, Chicago, Illinois 606 12, USA Correspondence to : Dr B. Duarte
Perforated duodenal diverticulum Duodenal diverticula are present in up to 20 per cent of the population but f e w patients require surgery ,for acute complications. Perforation is the rarest of these complications; only I01 afected patients have hetw reported in the world literature. These reports of perforated duodenal diverticulum are reviewed and strategies f o r the diagnosis and management of this unusual condition are discussed.
Since the incidence of duodenal diverticulum is second only to that of diverticulum of the colon, it is surprising that this lesion does not become symptomatic more often. The clinical presentation is non-specific and the diagnosis one of exclusion. Spontaneous perforation of a duodenal diverticulum is extremely rare: just over 100 cases have been reported in the world literature. Of these, only 13 were proven before operation by radiographic studies. Almost all of the reported cases required surgical treatment.
History and pathophysiology The first description of a duodenal diverticulum found at autopsy was made by Chomel in 1 7 1 0 ' ~ ~ More . than 200 years later, in 1916, Case demonstrated the condition on a radiograph3. In 1915, Forsell and Key diagnosed a diverticulum on an upper gastrointestinal radiograph using contrast agent and performed the first successful duodenal diverticulectomy I . As these radiographic studies became more frequently used, the reported incidence of duodenal diverticulum increased: it has varied from 1 to 5 per cent in upper gastrointestinal radiographic s t ~ d i e s ~ and - ~post-mortem analyses have shown incidences of up to 22 per cent6p8. The aetiology of the duodenal diverticulum remains unknown. The most widely accepted theory, however, implicates a weakness of the intestinal all',^.^. Diverticula are usually classified into three types. A true congenital diverticulum includes all the layers of the intestinal wall. This is the rarest type and is thought to result from an abortive attempt to form a supernumerary pancreas'. Only two perforations of a true congenital diverticulum have been reportedg. Primary acquired pulsion diverticulum, or pseudodiverticulum, is the commonest type. Possibly, these diverticula protrude through the weak areas of intestinal wall where blood vessels penetrate and contain only mucosal and serosal layer^',^,^. An alternative theory is that increased intraluminal duodenal pressure occurs secondary to a chronic duodenal obstruction caused by the superior mesenteric vessels crossing over the bowel". Secondary acquired diverticulum is the second commonest type and is believed to be caused by traction on a particular area of the duodenum by scarring or adhesions from a previous local inflammatory reaction (cholecystitis, lymphadenitis or duodenal ulcer). This type contains all the layers of the intestinal wall and is not a true diverticulum, simply an outpouching of the intestinal lumen. Secondary diverticula are found most frequently in the first part of the duodenum',2~'1. Most duodenal diverticula (88 per cent) are located along the pancreatic or mesenteric border, supporting the theory that they are caused by a weakness in the intestinal wall2. Approximately two-thirds are located in the second part of the duodenum and many are imbedded in the pancreas214. Most are within 2.5 cm of the ampulla of Vater and are therefore known as perivaterian; 16 per cent are multiple4.
0007-1323/9?/090877-05
1992 Butterworth-Heinernann Ltd
Clinical presentation The clinical diagnosis of diverticulum of the duodenum is difficult because there is no characteristic presentation. Symptoms are vague and non-specific, and lead the surgeon to consider other more common diseases such as cholecystitis, cholelithiasis, duodenal ulcer, gastritis and pancreatitis. The diagnosis is thus one of exclusion. Duodenal diverticula are commonly associated with other lesions of the gastrointestinal tract, such as diverticula elsewhere in the bowel, biliary tract disease, peptic ulcer and hiatus hernia'. The high incidence of other gastrointestinal diseases is probably related to the age of affected patients. Most are at least 50 years old, although perforation has been reported in a child and in a Not all diverticula are symptomatic, indeed most run a benign course, only 10 per cent having clinical relevance4. One isolated study has reported that 74 per cent of duodenal diverticula cause serious symptom^'^. The possible complications of duodenal diverticula are: common bile duct obstruction with cholangitis or jaundice; acute and chronic recurrent pancreatitis; partial duodenal obstruction; diverticulitis or peridiverticulitis; ulceration with or without haemorrhage; fistula to adjacent organs including the gallbladder, common bile duct, colon and aorta; enterolith formation with distal small intestinal obstruction or penetration into adjacent organs; malignant degeneration; torsion of the diverticulum; diarrhoea secondary to a blind loop syndrome; and perforation",' l.I5-l7.
Perforation Perforation is considered to be the most serious complication but fortunately it is also the rarest; only 101 patients so affected have been reported in the world literature. Juler et al." in 1969 published a collection of 56 cases and an additional 45 from the world literature are reported here (Table 1). All of the following data are from the total of 101 patients, except.where otherwise stated. In most patients (57 per cent) diverticulitis precedes and causes the perforation. This diverticulitis follows stasis and peptic digestion' I . The smaller the stoma into the diverticulum, the more likely it is that stasis will occur49. Other causes of perforation (Table 2 ) include enterolithiasis, ulceration, increased intraluminal pressure, presence of a foreign body, blunt abdominal trauma and the presence of a gallstone. Perforation of a duodenal diverticulum has no pathognomonic signs or symptoms. In most patients (78 per cent) the onset is acute with pain localized to the right upper abdomen or epigastrium, and associated nausea and vomiting. Some patients present with chronic abdominal pain, anorexia and malaise, which may have lasted as long as 1 month. Three patients in the literature reports presented with a history of months of steatorrhoea secondary to duodenocolic fistulae' 9-29334. The sequelae of perforation include retroperitoneal abscess,
877
F F
M
70 59
44
51
78
69
61
77
33
5
1970 1970
1970
1970
1970
1972
1972
1973
1973
1973
1974
Reilly and Kune2’
Reilly and Kune”
Cavanagh”
Miller et al.23
Wolfe and
Blomstedt and Holmz5
Peutz et a1.12
Peutz et a1.I2
Peutz et a/.”
Scarpa et
Dippon”
F
F
M
79
86
80
57
70
37
54
38
7s 49
1974
1974
1974
1975
1975
1976
1977
1971
1977 I978
Sicard et a1.”
Sicard et a/.28
de Medeiros et
de Medeiros et aL9
Kellum et al.29
Ettman and Kongtawng3’
Widder~hoven~’
Hansen and Taudorfis Glasser et
F F F
M
M
F
F
F
Acute Chronic
Acute
Acute
Chronic
Chronic
Acute
Acute
Acute
Acute
Acute
Chronic
M
73
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute Acute
Chronic
Acute
Symptom onset
F
M
F
F
F
F
M
Graudins”
55
1970
Dey and Latchmorel9
F
27
1969
Turner”
Sex
Year
Age (years)
Perforated duodenal diverticulum
n.a. Acute cholecystitis
Upper gastrointestinal bleeding/pancreatitis
Duodenocolic fistula
Perforated viscus
n.a
Colonic cancer, cholecystitis, appendicitis Appendicitis, cholecystitis
Mesenteric ischaemia
Perforated viscus
Tumour
Acute cholecystitis
Perforated ulcei
n.a
Perforated viscus
Acute cholecystitis
Perforated viscus
n.a.
n.a.
Perforated viscus
Duodenocolic fistula
Acute cholecystitis
Preoperative diagnosis
Reported cases of perforated duodenal diverticulum, 1969-1990
Reference
Table I
3rd 2nd
2nd
2nd
3rd
2nd
2nd
2nd
2nd
2nd
2nd
2nd
2nd
ma.
2nd
2nd
ma.
2nd
2nd
2nd
2nd
3rd
2nd
Part of duodenum
Anterior
Whipple procedure
Diverticulectomy/ serosal patch
Diverticulectorny/ droinoge/BII
Diverticulorrhaphy/ drainage Diverticulectomy/ drainage
Diverticnlectomy
Diverticulectomy
Diverticulectomy/ omental patch/ drainage
Diverticulectomy/ drainage Diverticulectomy/ drainage
Diverticulectomy/ drainage/BlI Diverticulectom y/ drainage Diverticulectomy/ drainage
Tube duodenostomy/ drainage No surgery
Diverticulectomy
Diverticulectomy Diverticulectomy
Diverticulectomy
Diverticulectomy
Treatment
Diverticulitis/enterolith Diverticulectomy Diverticulitis n.a. Diverticulectomy Diverticulitis
Diverticulitis
Pancreas Retroperitoneum Retroperitoneum
Diverticulitis
n.a.
n.a
n.a
Diverticulitis
n.a.
Diverticulitis
Diverticulitis
Enteroliths
Diverticulitis/foreign body Diverticulitis
Diverticulitis/gangrene
ma.
Enterolith
Increased intraluminal pressure Increased intraluminal pressure
Trauma (enterolith)
Ectopic gastric mucosa
Enterolith
Cause of perforation
Transverse colon
Retroperitoneum
Anterior
Anterior
Retroperitoneum
Retroperitoneum
Retroperitoneurn
Pancreas
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Pancreas
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Ascending colon
Retroperitoneum
Area of perforation
n.a. n.a. Normal Normal Ileus, RUQ calcification Air in paraduodenal area Retroperitoneal air UGI: normal
Death Survival Survival Survival Death
Shock
None None
Chest radiograph: normal n.a. RUQ calcification
Retroperitoneal aii (retrospective) Normal n.a Normal Free air UGI: diverticuluiu UGI/LGI: fistula, diverticulum UGI: fistula, free air, diverticulum n.a. Retroperitoneal air Paraduodenal air UGI: diverticulum
Survival Survival Survival
Survival Death Survival Death Survival Survival Death Survival ma. Survival
None
Pancreatic and small bowel fistulae None n.a. None
Pneumonia, duodcnal fistula None
Respiratory failure
Enterocutaneous fistula None
None
None
None
Normal
Survival
Survival None
Retroperitoneal fistula
n.a
Sepsis
None
ma.
UGIILGI: fistula Survival
Intra-abdominal abscess None
Radiographic findings* Enterolith (retrospective)
Result Survival
Complications
2‘
E
s
(D
? 4
s
0
3 m
C
c-
n
5.
P
E
3
(D
P
n
E v
0 P
W
4
0)
I-
?
m
68
32
n.a.
n.a.
85 87
61
89
64
1979
1980
1980
1981
1981
1982 1982
1983
1984
1984
1985
1985
1985
1988
1988
1989 1989
1989
1989
Yasui et a / . 3 4
Vorster and Tatdru-”
Manny et a/.14
Manny et 0 1 . ’ ~
Scudamore et a/.-’? Scudamore et d3’
Wells38
Zamir et a / . 3 9
Haugh and McBee4’
Stebbings and Thomson4’ Stebbings and Thomson4’ Beech et a/.42
Tissot et a/.4’
El Khatib44
Vanek et a/.45 Perrott“
Van Beers et d4’
Goodman et a/.48
,
Acute
Acute Acute
Acute
Acute
F F M
F
Acute
M
M
Acute
Acute
Acute
Acute
Acute
Chronic
Acute Acute
n.a.
Perforated duodenal diverticulum Perforated duodenal diverticulum
Perforated ulcer Acute cholecystitis
Perforated ulcer
Perforated duodenal diverticulum
Perforated duodenal diverticulum
Unknown
Small bowel obstruction
Acute cholecystitis
Acute cholecystitis
n.a.
Perforated viscus Perforated viscus
n.a.
ma.
n.a. Acute cholecystitis
Duodenocolic fistula
Duodenocolic fistula
ma.
Perforated ulcer
4th
4th
2nd 2nd
2nd
2nd
2nd
n.a.
n.a.
2nd
2nd
2nd
n.a. n.a. 2nd
ma.
2nd 2nd
2nd
2nd
2nd
2nd
Retroperitoneum
Retroperitoneum
Retroperitoneum Retroperitoneum
Retroperitoneum
Lesser sac
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Retroperitoneum
Anterior
n.a. n.a. n.a.
Retroperitoneum Retroperitoneum,’ pancreas ma.
Hepatic flexure
Ascending colon
Retroperitoneum
Retroperitoneum
Diverticulitis
n.a.
Enterolith ma.
Diverticulitis
n.a.
Diverticulitis
n.a.
ma.
n.a.
Increased intraluminal pressure Diverticulitis
ma.
Diverticulitis Diverticulitis Gallstones
Diverticulitis Diverticulitis
n.a.
ma.
ma.
ma.
Diverticulectomy
No surgery
Diverticulectomy Drainage
Diverticulectomy/ drainage
Diverticulectomy,’ drainage
Diverticulectomyitube duodenostomyi drainage Diverticulectomy/ drainage Diverticulectomy/ drainage Diverticulectomy/ drainage Tube duodenostomyi drainage; 6 weeks later, diverticulectomy
Diverticulectomy Diverticulectomy Tube duodenostomyi omental patch/ drainage Drainage
Diverticulectomy
Diverticulectomy Diverticulectomy
n.a.
Diverticulectomy/ vagotomyiBI1 n.a.
Diverticulectomyi drainage
None
None
Wound infection Sepsis
None
None
Metabolic alkalosis
None
Intra-abdominal abscess Duodenal fistula
None
None
Duodenal fistula
Pancreatitis
Duodenal fistula Duodenal fistula
None Duodenal fistula
None
None
None
Duodenal fistula
Survival
Survival
Survival Death
Survival
Survival
Survival
Survival
Survival
Survival
Survival
Survival
Survival Survival
Survival Survival
Survival
Survival
Survival
Survival
Survival
Survival
UGI/CT: perforated diverticulum CT: perforated diverticulum
Normal UGI: diverticulum
Normal
Retroperitoneal air UGI: diverticulum with extravasation and paraduodenal mass UGI: diverticulum with extravasation CT: abscess
Normal
Ileus
Normal
n.a.
US: pancreatic mass
UGI: diverticula
Normal
Paraduodenal air
Normal UGI: normal n.a. ma.
n.a.
UGI/LGI: fistula, diverticulum
UGI: fistula, diverticulum
UGI: diverticula
Normal
*Radiography was plain abdominal unless specified. ma., Not addressed in reference paper. BII, Billroth I1 gastrojejunostomy: UGI. upper gastrointestinal contrast radiography; LGI, lower gastrointestinal contrast radiography; RUQ, right upper quadrant of abdomen; US, ultrasonography of abdomen; CT, computed tomography
52
77
69
10
70
71
F
F
M
M
F
72
61
M
M F
n.a.
ma.
Acute
n.a.
Acute
F
Chronic
Chronic
Acute
Acute
F
M
F
F
M
55
73
50
1979
Yasui et a/.’4
70
56
1979
1979
Donald-’-’
Donald-’-’
D
L
2
(D
5
F
?
3
C
r,
3. c)
(D
2’
p
=L
(D
0.
0
C
P P
% (D
0,
-h
%
Perforated duodenal diverticulum:
B. Duarte et al.
Table 2 Causes o f duodenal diverticular perforation in I 0 1 patients
Cause of perforation Diverticulitis Enterolithiasis Ulceration Increased intraluminal pressure Foreign body
Trauma Gallstone Unknown/not specified
No. in series of Juler et al."
present series
Total*
40 6 9 0 1 0 0 0
19 6 0 3 1 1 1 16
59 (57) 12 (12) 9 (9) 3 (3) 2 (2) 1(1) 1(1) 16 (16)
Table 4 Area ofperforation of duodenal diverticula No. in
Location of perforation
No. in series of Juler et al."
Retroperitoneum Pancreas Colon Anterior Gallbladder Aorta Lesser sac Unknown/not specified
43 4 3 2 3 2 0 0
29 4 4 4 0 0 1 4
No. in
present series
Total*
Values in parentheses are percentages. *Two patients had more than one cause specified, giving a total of 103
Values in parentheses are percentages. *Two patients had more than one location specified, giving a total of 103
Table 3 Preoperative diagnoses considered in patients with perforated duodenal diverticula
improved preoperative and intraoperative diagnosis of this condition, there is still a mortality rate of 13 per cent in the series from 1969 to the present. This high rate may be caused in part by the advanced age of the patients and associated underlying diseases. Most perforations occur retroperitoneally, but the diverticulum may also perforate anteriorly, or into the pancreas, colon, gallbladder or aorta (Table 4 ) .
Preoperative diagnosis
No. in series of Juler et a/."
Cholecystitis 15 Perforated ulcer 12 Perforated duodenal diverticulum 3 7 Appendicitis Perforated viscus 0 0 Duodenocolic fistula Bowel obstruction 2 Upper gastrointestinal bleed 2 Colonic cancer/tumour 0 Mesenteric ischaemia 0 Pancreatitis 0 Unknown/not specified 5
No. in
present series
Total
10 4 5 2 7 4 1 1
2 1 1 11
Values in parentheses are percentages sepsis, mediastinitis27, duodenocolic fistula with steator,.hoeaI 9.29.34, and gastrointestinal tract bleeding secondary to perforation into the aorta". In most instances the preoperative diagnosis is incorrect. The most common erroneous diagnoses considered are cholecystitis, perforated viscus and appendicitis (Table 3). A correct preoperative radiographic diagnosis was made in 13 of the 101 patients. Plain abdominal radiographs may show periduodenal or retroperitoneal air, or they may be entirely normal. If the diverticulum perforates anteriorly, the radiograph may demonstrate a pneumoperitoneum. Fifty per cent of the plain radiographs obtained in this series were normal; only 27 per cent demonstrated retroperitoneal or paraduodenal air. Upper gastrointestinal radiographic studies may show a diverticulum with extravasation of contrast medium. Eighty per cent of such studies obtained in this series showed a diverticulum, but only seven of these demonstrated a fistula or extravasation of contrast medium. In three cases the diagnosis was confirmed by the use of abdominal computed t ~ m o g r a p h y ~ ~ , ~ 'and . ~ ' , endoscopic retrograde cholangiopancreatography confirmed the diagnosis in The duodenocolic fistulae were demonstrated by upper and lower gastrointestinal radiographic contrast studies. Juler et al." found that eight of 56 perforated duodenal diverticula were missed during operation up to 1969. The present series of 45 patients included only a single missed perforation, perhaps because surgeons today are more aware of perforated duodenal diverticuluin as a pathological entity. Juler et al. also reported an additional eight perforated diverticula diagnosed at autopsy without previous surgical intervention. Two cases of perforation diagnosed only at a ~ t o p s y ' ~are . ~reported ~ here. According to Juler et al. the mortality rate associated with perforated duodenal diverticulum from 1907 to 1969 was 34 per cent. Even in recent times, with increased awareness and
880
Management Surgical treatment is required for only 1-2 per cent of duodenal d i v e r t i ~ u l a ' * ~, diverticulectomy .~,~~ with two-layer closure of the duodenum is the treatment of choice4. Special care should be taken to avoid injury to the distal common bile duct and ampulla of Vater because most diverticula arise in this area. If perforation has occurred, the retroperitoneum should be drained. Complications of operations to repair the 46 perforated duodenal diverticula occurred in 41 per cent of the 45 patients in the present series. The most common complication was duodenal fistula (20 per cent). Two patients ( 4 per cent) had an intra-abdominal abscess, and five (11 per cent) had continued sepsis or sepsis-related complications. Pancreatitis developed after operation in one patient ( 2 per cent), and one sustained a wound infection. Reports have been made on two patients who were successfully treated with conservative therapy a l ~ n e ~ ' , ~Juler '. et al." previously described two cases managed nono p e r a t i ~ e l y;~however, ~ ~ ~ ' after reviewing the original reports it is clear that the patient described by Fischer" in 1958 actually had a cholecystoduodenal fistula that initially mimicked a perforated duodenal diverticulum on radiography. The patient reported by Shackletonso in 1963 had a perforated duodenal diverticulum demonstrated by upper gastrointestinal radiography. The perforated duodenal diverticulum reported by Van Beers et a / . in 1989 was documented by computed tomography4'. Both patients improved initially with intravenous fluids and parenteral antibiotics. Because of their improvement with conservative therapy, their advanced ages and underlying medical problems, non-operative therapy was continued. Both patients recovered.
References 1.
Odgers PNB. Duodenal diverticulosis. Br J Surg 1930: 17:
2.
Jones TW, Merendino KA. The perplexing duodenal diverticulum. Surgery 1960; 48: 1068-84. Case JT. Roentgen observations on the duodenum. A J R A m J
592-618. 3.
Roentgen01 1916; 3: 314-26.
4. 5.
Cattell RB, Mudge TJ. The surgical significance of duodenal diverticula. N Engl J Med 1952; 246: 317-24. Whitcomb JG. Duodenal diverticulum. Arch Surg 1964; 88: 275-8.
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Thompson NW. Invited commentary on transduodenal diverticulectomy for periampullar diverticula. World J Surg 1979; 3: 135-6.
Br. J . Surg., Vol. 79, No. 9, September 1992
Perforated duodenal diverticulum: B. Duarte et al. 7. 8.
9. 10. 11.
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
Baldwin WM. Duodenal diverticula in man. Anai Rec 1911; 5: 121-40. Ackermann W. Diverticula and variations of the duodenum. Ann Surg 1943; 117: 403-13. de Medeiros RP, Leonard LS, Mantovani M et al. Diverticulo duodenal verdadeiro perfurado. Rev Assoc Med Brasit 1975; 21: 367-8. Smith SRG, Goode AW. Nocturnal diarrhoea: a feature of giant duodenal diverticulum. Br J Surg 1984; 71: 647. Juler GL, List JW, Stemmer EA, Connolly JE. Perforating duodenal diverticulitis. Arch Surg 1969; 99: 572-8, Peutz WH, Sannen LJMJ, Sing LH. The perforated diverticulum of the duodenum. Arch Chir Neerlandicum 1973; 25: 313-18. Hahn 0. The surgery of duodenal diverticula. Beitrag zur Klinische Chirurg 1929; 148: 255-9. Manny J, Muga M, Eyal Z. The continuing clinical enigma of duodenal diverticulum. Am J Surg 1981; 142: 596-600. Hansen TT, Taudorf E. Diverticulum duodeni perforatum med retroperitonealt emfysem. Ugeskr Laeger 1977; 139: 653-4. Beachley MC, Lankau CA. Inflamed duodenal diverticulum: preoperative radiographicdiagnosis. Dig Dis 1977;22: 149-54. Brian JE, Stair JM. Noncolonic diverticular disease. Surg Gynecol Obstet 1985; 161: 189-95. Turner RJ. Acute duodenal diverticulitis. Tex Med 1969; 6 5 : 91-5. Dey KR, Latchmore AJC. Steatorrhoea due to duodeno-colic fistulae from perforation of a duodenal diverticulum with ectopic gastric epithelium. 5 r J Clin Pract 1970; 24: 444-5. Graudins J. Stflmpfes Bauchtrauma mit Perforation eines Duodenaldivertikels. Zentralbl Chir 1970; 4 : 129-31. Reilly PL, Kune GA. Perforation of duodenal diverticula: a new hypothesis. Aust N Z J Surg 1970; 40: 40-2. Cavanagh JE. Enteroliths and perforation of duodenal diverticula. Arch Surg 1970; 100: 614-18. Miller RE, McCabe RE, Salomon PF, Knox WG. Surgical complications of small bowel diverticula exclusive of Meckel's. Ann Surg 1970; 171: 202-10. Wolfe RD, Pearl MJ. Acute perforation of duodenal diverticulum with roentgenographic demonstration of localized retroperitoneal emphysema. Radiology 1972; 104: 301-2. Blomstedt B, Holm I. Treatment of perforated duodenal diverticu1a:report ofacase. ActaChirScand1972; 138:211-14. Scarpa FJ, Sherard S, Scott HW. Surgical management of perforated duodenal diverticula. Am J Surg 1974; 128: 105-7. Dippon R. Perforation eines Duodenaldivertikels. Helu Chir Acta 1974; 41: 121-2. Sicard JL, Prandi D, Hay JM, Maillard JN. Les complications des diverticules duodenaux; a propos de quatre observations. Ann Chir 1974; 28: 537-43. Kellum JM, Boucher JK, Ballinger WF. Serosal patch repair for benign duodenocolic fistula secondary to duodenal diverticulum. Am J Surg 1976; 131: 607-10. Ettman IK, Kongtawng T. Massive gastrointestinal bleeding and perforation of a duodenal diverticulum with coexisting pancreatitis. South Med J 1977; 70: 761-3.
Br. J. Surg., Vo1.'79, No. 9, September 1992
Widdershoven GMJ. Perforated perivaterian duodenal diverticulitis. Arch Chir Neerlandicum 1977; 29: 153-7. 32. Glasser CM, Goldman SM, Roda CLP, Bronstein HD. Preoperative diagnosis of a perforated duodenal diverticulum. AJR Am J Roentgenol 1978; 130: 563-4. 33. Donald JW. Major complications of small bowel diverticula. Ann Surg 1979; 190: 183-8. 34. Yasui K, Tsukaguchi I, Ohara S ei a/. Benign duodenocolic fistula due to duodenal diverticulum: report of two cases. Radiology 1979; 130: 67-70. 35. Vorster CF, Tataru V. Das gedeckt perforierte und massiv blutende Duodenaldivertikel.Munch Med Wochenschr 1980; 122: 715-16. 36. Cox CL. Perforated duodenal diverticulitis. South Med J 1980; 73: 830. 37. Scudamore CH, Harrison RC, White TT. Management of duodenal diverticula. Can J Surg 1982; 25: 311-14. 38. Wells F. Pancreatic abscess complicating a perforated duodenal diverticulum. Br J Surg 1983; 70: 292. 39. Zamir 0, Lernau OZ, Nissen S. Tube duodenostomy - a safe method for managing perforated duodenal diverticulum. Can J Surg 1984; 27: 421. 40. Haugh DC, McBee MH. Perforation of duodenal diverticula. Contemp Surg 1984; 25: 12-5. 41. Stebbings WSL, Thomson JPS. Perforated duodenal diverticu1um:areport oftwocases. PosfgradMedJ1985;61:839-40. 42. Beech RR, Friesen DL, Shield CF. Perforated duodenal diverticulum: treatment by tube duodenostomy. Curr Surg 1985; Nov-Dec: 462-5. 43. Tissot E, Ayoun CL, Maisonnier M. Diagnostic preopiratoire d'une perforation subaigue d'un diverticule duodenal. J Chir (Paris) 1988; 125: 346-9. 44. El Khatib C . Perforated duodenal diverticulitis. W V Med J 1988; 84: 663-4. 45. Vanek VW, McNamara K, Lyras LS. Perforated duodenal diverticulum: case report and literature review. Contemp Surg 1989; 34: 36-47. 46. Perrott CAV. Perforated duodenal diverticulum - an oftenmissed diagnosis: a case report. S Afr J Surg 1989; 27: 24-5. 47. Van Beers B, Trigaux JP, De Ronde T, Melange M. Case report: CT findings of perforated duodenal diverticulitis. J Comput Assist Tomogr 1989; 13: 528-30. 48. Goodman P, Raval B, Zimmerman G. CT diagnosis of perforated duodenal diverticulum. Clin Imaging 1989; 13: 321 -2. 49. Neil1 SA, Thompson NW. The complications of duodenal diverticula and their management. Surg Gynecol Obstet 1965; 120: 1251-8. 50. Shackleton ME. Perforation of a duodenal diverticulum with massive retroperitoneal emphysema. N Z Med J 1963;62:93-4. 51. Fischer F. Gleichzeitiges Vorkommen einer durch Steinperforation entstandenen inneren Gallenfistel mit einem Duodenaldivertikel, zugleich ein Beitrag zur Differentialdiagnose des Bulbusdivertikels. Radio1 Clin 1958; 27: 35-9. 31.
Paper accepted 27 February 1992
881
